Prepared by Division of Medical Quality Assurance
REAPPLICATION FOR CANDIDATES REQUESTING
SPECIAL TESTING ACCOMMODATIONS
IN ACCORDANCE WITH THE
AMERICANS WITH DISABILITIES ACT
Reapplication has only one part and must be completed by the candidate.
Instructions:
A. Who Should File the Application: Only previously accommodated candidates seeking special
B.
C.
D.
E.
F.
G.
testing accommodation for an Americans with Disabilities Act (ADA) disability should use this
form. Use form DH-MQA 4000 if you are requesting a special testing accommodation for the
first time. Use form DH-MQA 4001 if requesting an accommodation due to a religious conflict
and use form DH-MQA 1192 if requesting the use of a translation dictionary.
Application Submission Deadline: Completed applications must be submitted at least 60 days
prior to the examination for which you are requesting special testing accommodations. If
submitted with less than 60 days until the examination, the department will provide any such
requested accommodation that can be made available without posing undue burden or
jeopardizing the security and integrity of the examination. If a candidate who requires an
accommodation fails to timely request such, then the candidate must reschedule their
examination date.
Required Documentation: If a complete and approved Part II of the Application for Candidates
Requesting Special Testing Accommodations in Accordance with the ADA is on file and no
changes have occurred in your disability, you do not need to re-file Part II of the application.
Review: A review of each application will be completed after each submission. The department
will defer the review of each application until all necessary documentation is completed and
submitted.
Type or Print All Information on the Application: Do not leave sections blank, insert ¡°N/A¡± if
the section does not apply.
Emailing Information: For faster service submit your reapplication and any supplemental
documentation you are sending with your application to the following email address:
mqa.specialtesting@.
Mailing information: If you cannot email your application, submit your application and any
supplemental documentation you are sending with your application to the following address:
Florida Department of Health
Division of Medical Quality Assurance
ATTENTION: ADA Accommodations
4052 Bald Cypress Way, Bin # C-91
Tallahassee, FL 32399-3250
DH-MQA 1191, Revised 10/2020
1
Note:
¡ñ Send via email or mail. Do not send your application for special testing accommodations by
both email and mail.
¡ñ Do not send your request for special testing accommodations reapplication to the board
office.
¡ñ Do not mail your application for licensure or examination to this address because this will
delay action on your reapplication.
REAPPLICATION FOR CANDIDATES REQUESTING
SPECIAL TESTING ACCOMMODATIONS IN ACCORDANCE
WITH THE AMERICANS WITH DISABILITIES ACT
SECTION 1: PERSONAL DATA
1. Name:______________________________________________________________
First
Middle
Last
Date of Birth: _____________________
_____________
______________
Month
Day
Year
2. Mailing Address: _______________________________________________________
Street
Apt. Number
___________________________________________________________________________
City
State
ZIP Code
Email: _____________________________________________________________________
3. Phone Number: (____) ________________ (Mobile)
(____) ________________ (Work)
SECTION 2: EXAMINATION FOR WHICH ACCOMMODATION IS REQUESTED
1. Profession: _________________________________________________________________
2. Month / Year of Exam: ________________________________________________________
3. Name of the Examination (check all those that pertain and identify by name):
___ (1) Laws and Rules
DH-MQA 1191, Revised 10/2020
2
___ (2) National
___ (a) Practical __________
___ (b) Written __________
___ (c) Specialty(ies) (if applicable): __________
___ (3) State Exam
___ (a) Practical __________
___ (b) Specialty(ies) (if applicable): __________
___ (4) Other (explain): ___________________________
SECTION 3: FORMER SPECIAL TESTING ACCOMMODATION(S)
1. What was the date of the last examination for which Testing Services in Florida provided
special testing accommodations? ________________________________________________
____________________________________________________________________________
2. Have there been any changes in your disability?
____ Yes
___ No
3. If Yes, please explain: __________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
4. What accommodations were provided? (Check all that apply)
____ Extra time
Amount of extra time provided: _______________
____ Separate room
____ Other (please list): ________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
SECTION 4: Certification
I certify that the above information is true and accurate. If the test accommodations granted to me
include a deviation from the standard testing time schedule, I agree that, from the time I begin the
examination until I have completed it, I will not communicate in any way, to the extent possible, with
any other individuals taking the examination and I will not communicate in any way with any such
individuals about the content of the examination.
DH-MQA 1191, Revised 10/2020
3
Signature: ___________________________________
Date: __________________
I understand the Department of Health will use the information obtained by this authorization to
determine eligibility for a reasonable accommodation in regard to this examination by reason of my
disability. This information will remain confidential pursuant to the provisions in Section 456.014,
Florida Statutes. If clarification or further information regarding the documentation provided is
needed, I authorize the Department of Health authority to contact the professional(s) who diagnosed
the disability and/or those entities to communicate with the Department of Health in this regard to
provide the Department with such clarification and/or further information.
Signature: ___________________________________
DH-MQA 1191, Revised 10/2020
Date: __________________
4
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